Update 2012-02-15
1

A. Understand how health insurance relates to your personal financial plan
B. Understand basic health insurance coverage and provisions
C. Understand the Key Areas of Disability
Insurance
D. Understand the Key Areas of Long-term Care
Insurance
E. Understand how to control health care costs
2


What does health insurance do?
•
It protects you and your dependents from financial catastrophe
•
It provides the necessary care should you or your dependents become hurt or injured
•
It provides peace of mind
3


President N. Eldon Tanner commented:
• Nothing seems so certain as the unexpected in our lives. With rising medical costs, health insurance is the only way most families can meet serious accident, illness, or maternity costs, particularly those for premature births. . . Every family should make provision for proper health and life insurance
( N. Eldon Tanner, “Constancy Amid Change,”
Ensign, Nov. 1979, 80).
4


What are the major types of Health Care
Coverage?
• The four major types of Health Care Coverage are:
• I. Basic health insurance
• II. Major medical expense insurance
• III. Dental and eye insurance
• IV. Dread disease and accident insurance
5


What is basic health insurance?
• This is basic health coverage which covers hospital, surgical and physician expense insurance

What three areas does basic health insurance cover?
• Hospital insurance. This covers hospitalization expenses including room, board, nursing, and drug fees
• Surgical insurance. This covers only the direct costs of surgery including the surgeon’s and equipment fees
• Physician expense insurance. This covers physicians’ fees including office, lab, X-ray, and fees for other needed tests
6

What is Major Medical Insurance?

This is major coverage of medical costs over and above the basic health insurance coverage
What does it cover?
 Medical costs beyond the basic plan. These normally require a co-payment and/or a deductible
 A stop-loss provision. This limits the total out-ofpocket expenses incurred by the insured to a specific dollar amount

A life-time cap for the insurance company. This limits the total amount the insurance company will pay over the life of a policy
7


What is Dental and Eye Insurance?
• This is insurance which covers only dental work and expenses relating to the eyes

What does it cover?
• Generally, it is only partial costs of eye exams, glasses, contact lenses, dental work, and dentures.
• Know your coverage, as the amount covered varies by plan provider
• These plans are generally expensive, unless they are provided as part of an employer plan
• Know what your plan covers before you go
8


What is Dread Disease and Accident Insurance?
• It is special insurance to cover a specific type of disease or accident

What does it cover?
• Generally it provides only for ‘specific’ illnesses or accidents on the “covered” list
• It provides a set maximum dollar amount of reimbursement

This insurance is generally expensive, unless included in your company’s total health plan.
• Generally, concentrate on making your health coverage as comprehensive as possible 9


Who are the three major providers of health care?
• 1. Private health care plans
• Fee-for-service (or traditional indemnity plans)
• Managed health care (HMO, PPO)
• 2. Non-group (individual) health care plans
•
3. Government-sponsored health care plans
10


What are private health care plans?
• These are health care plans sold by private insurance companies to individuals and employers as part of a benefits package

What are fee for-service or traditional indemnity plans?
• These are health care plans where the doctor bills the patient directly, and the patient is reimbursed, to a specific percentage, by the insurance company
11

(continued)

What are their advantages?
• They provide the greatest flexibility for choosing doctors and hospitals.
• They define the percent of each claim the policy will cover
• They define the amount the insured must pay before a claim is eligible for reimbursement

What are their disadvantages?
• Generally these plans are expensive and require more paperwork
12

(continued)

What are managed health care providers?
• These are insurance companies which provide prepaid health care plans to employers and individuals.
• There are four main types of managed care:
• i. Health maintenance organizations (HMOs)
• ii. Preferred provider organizations (PPOs)
• iii. POS Plans (POS)
• iv. Exclusive Provider organization (EPOs)
13

(continued)

What are their advantages?
• They pay for and provide health care services to policy holders
• They provide the most efficient payment of bills

What are their disadvantages?
• They limit choices to the doctors and hospitals that participate.
• They require policy holders to pay a monthly premium and share the cost of care.
14

 i. Health Maintenance Organizations
(HMOs)?
• HMOs are prepaid insurance plans which entitle members to the services of specific doctors, hospitals and clinics.
• They are the most popular form of managed health care, due to their costs, which are roughly 60% of fee-for-service plans
15

(continued)

What are their advantages?
• They provide a system of doctors and hospitals for a flat fee, and emphasize preventive medicine and efficiency
• Subscribers pay a relatively small co-pay for services rendered

What are their disadvantages?
• They provide little choice of doctors and hospitals.
As such, service may be less than at other facilities and referrals sometimes difficult to get
• Generally, gatekeeper physicals are used
16

(continued)
 ii. Preferred Provider Organizations (PPOs)?
• PPOs are insurance plans which are essentially a cross between the traditional fee-for-service and an
HMO.
• PPOs are organizations where in-plan providers fees are covered, and out-of-plan providers results in higher fees
• Insurers negotiate with a group of doctors and hospitals to provide care at reduced rates, while giving insurers the ability to go to non-plan doctors
17

(continued)

What are their advantages?
• PPOs provides health care at a discount to fee-forservice plans
• They provide a group of doctors which work at reduced costs to the participants, while assessing an additional fee if the participant uses a non-member doctor or center

What are their disadvantages?
• PPOs are more expensive than HMOs
• Use of non-PPO providers results in higher out-ofpocket costs
18

(continued)
 iii. Point of Service Plans (POS)
• Has attributes of HMOs, PPOs, and indemnity plans
• The point at which benefits are received determines the amounts of benefits paid
• POS may include HMO, PPO, and indemnity type programs
• POS may also have a gatekeeper
19

(continued)
 iv. Exclusive Provider Organization (EPO)
• Similar to an HMO, but operates through an insurance company.
• It is funded through an insurance company, with health care provided by contracted providers
• Only care received from contracted providers is covered (unless in an emergency situation)
20


What are non-group or individual health care plans?
• These are health insurance plans which cover individuals on a case-by-case basis
• These are traditionally the most expensive type of coverage
21

(continued)

What are their advantages?
• They provide a custom insurance policy to the purchaser

What are their disadvantages?
• They are expensive, usually 15% - 60% more expensive than a group policy
• They may require subscribers to pass a medical exam
22

(continued)

When switching between jobs, utilize COBRA if available
• Before you sign up for non-group coverage health care plans, check the company ratings and claim service
• Avoid a company that raises premiums with claims and that has policies which can be cancelled
23


What are government-sponsored health care plans?
• These are insurance plans which are sponsored either by the state or the federal government
• These plans fall under three headings: i. Workers’ Compensation ii. Medicare iii. Medicaid
24

 What is Workers’ Compensation?
• Workers compensation is state insurance program that insures against work-related accidents and illness

What are its advantages?
• Workers’ Compensation provides insurance to workers injured on the job, regardless of whether they have other health insurance or not

What are its disadvantages
• It only covers work-related accidents and illnesses
• Coverage is determined by state law and varies state by state 25


What is Medicare insurance?
• Medicare insurance provides medical benefits to the disabled and to those 65 and older who are covered by Social Security.
• Its cost is covered through Social Security taxes

What are the advantages?
• Individuals can get insurance that would be prohibitively expensive through other channels

What are the disadvantages
• It doesn’t cover all the costs and expenses
26

(continued)

Medicare is Divided into three parts: A,B, C
• Medicare Part A is compulsory and covers all hospital related expenses, such as bed and board, operating room costs, and lab tests. Patient pays a deductible and coinsurance payment
• Medicare Part B is voluntary, with a monthly charge. It covers doctors’ fees and other outpatient treatment. Patient pays a premium, deductible, and
20% of approved charges
• Medicare Part C (Medicare Advantage) provides three program alternatives: coordinated care plans, private fee-for-service Medicare, and health savings accounts (HSAs)
27

(continued)
 What doesn’t Medicare cover?
• Medicare doesn’t cover the total costs for all services. You must pay certain amounts
• In addition, there are limitations to the coverage, such as out-of-hospital prescription drugs and limitations to the number of days in skilled nursing facilities
28

(continued)

What is Medigap insurance?
• Medigap Insurance is insurance which covers the gaps between the two parts of Medicare. It is sold by private companies, provides for the gaps in
Medicare coverage
 What are the advantages of Medigap insurance?
• It covers the additional costs of Medicare insurance
• It is limited by Federal law to 10 standardized contracts (A-J), except in 3 states
• It Can’t be rejected for health reasons if you enroll within 6 months of enrolling in Medicare Part B
 What are the disadvantages
• It is expensive, so shop around as the costs vary
29


What is Medicaid insurance?
• Medicaid is a medical assistance program, operated jointly by the states and federal government, to provide health care coverage to low income, blind, or aged persons

What are its advantages?
• Medicaid payments may be used to offset the premiums, deductibles, and co-payments incurred with Medicare.

What are its disadvantages
• There is no guarantee that this plan will be around in its present form
30


Any questions on basic health insurance plans?
31


What is disability insurance?
• Disability is similar to life insurance, but is really
“earning-power” insurance
• Insurance that in the event that income is interrupted due to illness, sickness, or accident, you will still have income
• Who needs disability insurance?
• Anyone who depends on income from a job
• What are the odds of being disabled?
• The Social Security Administration states:
“Studies show that a 20-year-old worker has a
3-in-10 chance of becoming disabled before reaching retirement age.” http://www.ssa.gov/dibplan/
32

(continued)

What are the sources of disability insurance?
• Employers
• Government
• Private providers
• The definition of disability from an employer can be different than from an individual policy
 Isn’t worker’s compensation sufficient?
• What about if the accident is not work-related?
• Coverage is determined by individual states, with wide variability
• Social Security benefits vary depending on how many years you have paid into the system, your salary, how long the disability is expected to last 33

(continued)

How much coverage should I have?
• You should have enough coverage to maintain your living standard should you no longer be able to work
• Your investment income will not stop with a disability, but your income from working will stop
• If you have sufficient savings, you may not need much insurance, perhaps only 30% of after-tax income
• If you have little savings, you may need a lot, perhaps 80%
34

(continued)

What are the key areas of disability insurance?
• 1. Definition of disability
• What exactly does the policy consider a disability?
• Stick with a policy that defines disability as an inability to perform your normal job.
• A combination definition may include “if you can’t perform your normal job for the first 2 years, and afterwards any occupation for which you are reasonably suited” may be acceptable
35

(continued)

2. Residual or part-time payments when returning to work part-time
• Some policies offer partial disability payments that allow workers to return to work part-time
• These payments make up the difference between part-time and full-time work
36

(continued)

3. Benefit Duration
• Policies state how long the benefits will continue
• Most policies provide benefits for a maximum period or until the disability ends (or the disabled reaches age 65 or 70).
• Short-term disability policies generally provide benefits from 6 months to 2 years, after a wait of
8 to 20 days
• Only a long-term policy makes much sense.
Your emergency fund protects short-term
37

(continued)

4. Waiting or Elimination Period
• Policies determine the waiting period before the benefits begin
• Most policies have waiting periods of between 1 and 6 months.
• Generally the longer the waiting period, the less-expensive the policy
38

(continued)

5. Waiver of Premium
• What is the waiver of premium?
• It is a good idea to have a waiver of premium provision, which waives the premium payments if you become disabled

6. Non cancelable
• Make sure your policy is one that cannot be cancelled. This protects you and guarantees your policy is renewable
39

(continued)

7. Rehabilitation Coverage
• What is the rehabilitation coverage?
• This provides for vocational rehabilitation, allowing the policyholder to be retrained for employment through employment-related educational and job-training programs.

8. Cost of Living Rider
• This provides for inflation adjustments to protect you from the impact of inflation
40

(continued)

How expensive is disability coverage?
• Generally, the annual premium will be around 1-
2% of the income replaced
• Example:
• A policy replacing $50,000 per year of annual salary would cost about $1,000 per year.
• It can be expensive, but may be cheaper if you get it through your work
41


42


What is long-term care (LTC) and long term care insurance (LTCI)?
• LTCI covers the costs the cost of nursing home and long-term home health care expenses

What are its advantages?
• It provides a daily dollar benefit for the costs of long-term care
• It provides help to those with a family history of long-term disabilities

What are its disadvantages?
• It is expensive, with many exceptions and conditions for coverage
43

(continued)

The four main providers of Long term care are:
• Self-insurance
• Medicaid
• Medicare
• Long Term Care Insurance
44

(continued)

Key Provisions (which control qualification for benefits)
• Type of care covered
• Benefit period
• Waiting period
• Inflation adjustment provision
• Waiver of premium provision
• Non-cancelability provision
45

(continued)

Key areas of long-term care insurance
• Comprehensive or facilities-only plans
• Daily Benefit Amount
• Benefit Period
• Elimination Period
• Inflation adjustments
46

(continued)

1. Comprehensive or facilities only plans
• Comprehensive plans help pay for care received at home as well as in LTC facilities.
• Facilities only plans require care at LTC facilities, which include nursing homes, assisted living or residential care facilities, and hospice and respite care facilities
• Facilities only plans are generally cheaper
47

(continued)

2. Daily Benefit Amount
• This amount is either the maximum amount or the actual amount the insurance will pay per day for covered services
• Some contracts offer benefits on a monthly or weekly basis
• Understand the rules for any policy you may be considering
48

(continued)

3. Benefit period
• This is the amount of time that you wish to receive the daily benefit amount
• The period can range from 2 to 10 years or for an unlimited amount of time
• Your total lifetime benefit is your daily benefit * your benefit period
• If your benefit amount is $110 * 1,825 days (5 years), your lifetime benefit is $200,750
49

(continued)

4. Elimination or waiting period
• Your elimination period is a period of time during which you are eligible for benefits before the insurance company will begin paying your claim
• Policies with short or no elimination period are more expensive than those with longer elimination periods
50

(continued)

5. Inflation protection
• There are a number of options to help you protect yourself against the increased costs of care in the future
• You can add options for automatic compound inflation, simple inflation, periodic inflation, or future purchases.
51


Any questions on long-term care insurance?
52


The best methods of controlling health care costs are:
• 1. Live a healthy lifestyle
• 2. Use a group plan (if available)
• 3. Use a medical reimbursement or flexible spending account
• 4. Use a Health Savings Account
• 5. Consider COBRA when changing jobs
• 6. Choose no health care coverage if you already have coverage through a spouse (this is not recommended unless already have coverage )
53


Live a healthy lifestyle

Get adequate exercise

Live long enough to be a challenge to your kids
 Get adequate sleep

Early to rise and early to bed, makes a man healthy, wealthy and dead?

Take care of your body

Live the Word of Wisdom both in word and spirit

Maintain your relationships of family and friends

Family and friends truly make a difference
54


Group health care plans may be more desirable than individual plans for three reasons:
• Generally, participants can get group coverage at lower rates
• Employers often provide group coverage as an employee benefit
• Persons with existing health problems may find it easier to obtain group coverage because the underwriting is based on the group rather than the individual
55


What is a Medical Reimbursement Account?

It is an optional employer-established savings plan that allows you to pay un-reimbursed medical expenses with pre-tax dollars

What are its advantages?
 It allows you to pay unreimbursed medical expenses with pre-tax dollars
 It is very flexible, and covers many items

What are its disadvantages?

Some expenses are not eligible for coverage.

You must use it by year-end or you lose it!
56


What is a health savings account (HSA)?

Health savings accounts are new options to help people pay medical expenses

For 2012, almost anyone with a qualified highdeductible health plan (which is a plan with a minimum deductible of $1,200 for self and
$2,400 for a family) can also have an HSA.

Contributions can be made by an individual or an employer ($3,100 self, $6,250 family, with catch up limits for those over 55 of $1,000)
 Individuals contribute each year into an account that grows tax-free to pay for future qualified medical and retiree health expenses
57

(continued)
Contributions: Self
Health Savings Plan Limits
Family Catch Up >
Age 55
2008
2009
$2,850
3,000
$5,800
5,950
$900
1,000
2010
2011
2012
Deductibles:
2008
2009
2010
2011
2012
3,050
3,050
3,100
1,100
1,150
1,200
1,200
1,200
6,150
6,150
6,250
2,200
2,300
2,400
2,400
2,400
1,000
1,000
1,000
58

2008
2009
2010
2011
2012
Health Savings Plan Limits
Maximum Out of Pocket Expenses:
Self
$5,600
Family
$11,200
5,800
5,950
5,950
6,250
11,600
11,900
11,900
12,100
59

(continued)

What are its advantages?
• You are paying for “qualified medical expenses” on a tax-free basis
• Can be used to pay for medical expenses before you reach your deductible limits
• Earnings grow tax-free, and carry over
• Distributions may be used for spouse or kids

What are its disadvantages?
• Deductibles are high
• If distribution is not for qualified expenses, then the distribution is included in income and subject to a
10% penalty (no penalty if taken after age 65)
• Not for the seriously ill
60


What is COBRA?
•
COBRA, an acronym for the Consolidated
Omnibus Reconciliation Act, requires that a company of more than 20 employees continue to offer group health care to former employees, retirees, spouses and dependents with a length of coverage, depending on the reason for leaving, generally for 18 months at your cost
61

(continued)

What are the advantages?
• You can have health insurance between jobs

What are the disadvantages?
• You must pay the premium which can be substantially higher than before you left
• You must notify the company within 60 days of leaving that you are going to use COBRA
62


What is opting out?

It is a cash incentive, offered by many companies, for refusing insurance coverage for yourself or family.

What are its advantages?
 It may be an option if you have other coverage through a spouse and can be assured of not losing the spouse’s coverage.

What are its disadvantages?

If you opt out without other coverage, you are taking a very dangerous risk
63

1. Always compare rates
• Consider only high-quality insurance companies.
• Check with AM Best at http://www.ambest.com/ and other insurance rating companies for stability
2. First protect yourself from the catastrophic illness or accident
• Avoid policies with major exclusions or exemptions
• Make sure your policy has a sufficiently high cap
• Get the “needed” major coverage first before the
“nice” coverage
64

(continued)
3. Buy an individual policy if not covered at work
• Consider joining a PPO or HMO to reduce costs
• Group plans are generally less expensive
• Consider a high deductible health savings account
(HSA)
4. Consider higher deductibles to reduce premiums
• Consider raising deductibles to get better coverage
• Avoid polices that are not guaranteed renewable or that have a low minimum lifetime coverage amount
65


To protect your health and your financial plan, the following essential questions should be asked. These questions and major ideas were taken from Lisa Collier
Cool in the April 2006 Readers Digest. She recommends:
66

(continued)
• 1. What is the real bottom line.
• Determine the total costs of your health insurance. Total costs include not just the annual costs, but any deductibles for lab work, emergency care, and other coverage.
• Make sure the deductible is annual, and not for every time you visit the doctor.
• Also understand what it takes to reach the family deductible.
• In addition, weigh co-payments for lab tests, hospital care, emergency room visits, etc.
67

(continued)
• Finally, make sure you know your annual out-ofpocket maximum, or the maximum you will have to spend each year before the health plan pays 100% of all additional costs.
• 2. How well protected are you from catastrophic costs?
• Check your plan to determine the limits the insurance company will pay over you or a member of your family’s lifetime.
• A low cap, such as $100,000, would leave you exposed to additional costs over that amount from a major accident or disease.
68

(continued)
• 3. Will you be able to use your regular doctors?
• Check the list of available doctors and hospitals for any plan that you are considering.
• Since many doctors may accept a range of plans, discuss with your current doctor which plans they accept, and if they would consider working with your “prospective” new health plan.
69

(continued)
• 4. How complicated is it to see a specialist?
• With most of these plans, there generally is a medical “gatekeeper” that you must work through to see a specialist.
• This gatekeeper decides whether or not the referral is necessary. Depending on your type of plan, it could be harder to see specific specialists.
• Make sure you understand what you are getting into before you commit.
70

(continued)
• 5. Do you have a choice of hospitals?
• Most insurance plans are associated with specific hospitals and doctors.
• Check to make sure that the plan covers your doctors and the hospital they are affiliated with, as well as any nearby hospitals where you may be treated in an emergency.
• Also determine how your care would be handled if you were sick or hurt while traveling.
71

(continued)
• 6. Are your prescriptions covered?
• If you plan includes prescription coverage, ask for its “formulary” or the list of prescription drugs it covers.
• Some plans have a tiered coverage where coverage is grouped into different groups.
• Some drugs may not be covered at all if the insurance company considers that group of drugs experiments.
72

(continued)
• 7. What other benefits are included?
• In addition to health care, some policies may also cover additional areas, such as dental and vision care, hear aids, and other items.
• In addition, many also include services to keep you healthy, including discounts on gym memberships, weight loss, and smoking cessation programs. (Lisa Collier Cool, “7
Key Questions to Ask,”
Readers Digest ,
April 2006, pp. 102-103)
73

A. Do you understand how health insurance relates to your personal financial plan?
B. Do you understand basic health insurance coverage and provisions?
C. Do you understand the Key Areas of
Disability Insurance?
D. Do you understand the Key Areas of Longterm Care Insurance?
E. Do you know how to control your health care costs?
74

Data

Steven has a $1 million major medical policy with a
$500 deductible, an 80% co-insurance provisions, and a $5,000 stop-loss limit. He recently incurred
$10,500 of covered medical expenses.
Calculations

What amount will the insurer pay in this situation?

How much will Steven pay?
75

Steven has a $1 million major medical policy with a $500 deductible, an
80% co-insurance provisions, and a $5,000 stop-loss limit. He recently incurred $10,500 of covered medical expenses. What amount will the insurer pay in this situation? How much will Steven pay?
76


The insured pays the deductible first ($500), then the insurance company and the insured split the remainder
(80%/20%), up to the stop-loss limit of the insured
($5,000).
Total Expenses $10,500 Insurer Pays Steven Pays
Deductible 500 $0 $500
Remaining 10,000 80/20 split 8,000 2,000
Total Payments $10,500 $8,000 $2,500
77